U.S. District Judge Cecilia M. Altonaga has sentenced Enrique Gonzalez (Gonzalez), a former Miami HIV infusion clinic director, to serve 70 months in prison for his role in a $26.2 million HIV infusion fraud scheme and ordered him to pay $17,590,896 in restitution to HHS, according to a Department of Justice (DOJ) announcement. In addition to his prison term, Gonzalez will serve three years of supervised release. On November 13, 2012, Gonzalez pleaded guilty to one count of conspiracy to defraud the United States, to cause the submission of false claims, and pay health care kickbacks and one count of conspiracy to commit health care fraud. Gonzalez admitted that during his association with Physicians Med-Care, the clinic billed the Medicare program approximately $24.5 million in HIV infusion therapy claims, for which the clinic received $16.7 million in payments. In addition, during his time with Physicians Health, the clinic billed Medicare approximately $1.7 million. He received approximately $800,000 in payment from the Medicare program for fraudulent services.

The Scheme

According to the DOJ, Gonzalez admitted that between August 2002 and March 2004, he conspired with co-defendant Ronald Harris (Harris), a Miami physician, to operate Physicians Med-Care and Physicians Health, two Miami HIV infusion clinics (physicians clinics), which were owned and controlled by alleged co-conspirators Carlos Benitez and his brother Luis Benitez. Although the physician clinics claimed to specialize in treating patients with HIV, according to the court documents, the sole purpose of their operation was to committing Medicare fraud. Gonzalez, who was a director of Physicians Med-Care, also admitted that he agreed with his co-conspirators to handle the finances for the physician’s clinics by moving the money paid by the Medicare program out of the physician clinics’ accounts and into accounts owned and controlled by his co-conspirators, the DOJ said. Under the direction of his co-conspirators, Harris signed blank checks that Gonzalez used to transfer funds to various Benitez-owned entities and others. In addition, Gonzalez agreed to provide cash to various co-conspirators at the physician clinics to be used to pay bribes and kickbacks to the Medicare beneficiaries in return for those beneficiaries allowing the physician clinics to bill the Medicare program for HIV infusion services that were not medically necessary and often not provided, the DOJ reported.

Other Conspirators’ Charges

In connection with his role as medical director for the Physicians clinics, Harris pleaded guilty on August 26, 2008, to one count of conspiracy to defraud the United States, to cause the submission of false claims and to pay health care kickbacks; one count of conspiracy to commit health care fraud; and three counts of submitting false claims to the Medicare program. He was sentenced to serve 84 months in prison for his role in the scheme, DOJ said. Carlos and Luis Benitez and Thomas McKenzie were charged separately with health care fraud and money laundering crimes for committing approximately $109 million in HIV infusion fraud and money laundering through the physician clinics and nine other HIV infusion clinics in an indictment unsealed on June 11, 2008. Court records show that they provided the money and staff necessary to open the physicians clinics, the Medicare patients that the clinics needed to bill the Medicare program, and transportation for the HIV patients who visited the clinics. McKenzie pled guilty to one count of conspiracy to commit health care fraud and one count of submitting false claims to the Medicare program, and admitted to his role in a $119 million HIV infusion fraud scheme. He was sentenced to serve 14 years in prison. Carlos and Luis Benitez are fugitives.

In the aftermath of the Newtown, Connecticut elementary school shootings the focus has been on guns. We have heard the arguments. On one side there is the belief that mandatory background checks, the banning of certain assault-style weapons, and the elimination of large ammunition magazines will make the difference. On the other side, there is the view that the Second Amendment gives law-abiding citizens the unfettered right to keep and bear arms and that these proposed restrictions are just a first step in an attempt to disarm the public. Others have expressed concern over the effect that violence in our music, video games, movies, and TV have had on our citizens, particularly our youth. Although a debate over these issues is certainly appropriate, one common thread runs through many of these mass shootings. The shooters displayed signs of mental health problems prior to the killings.

Mental Illness, Homicide and Suicide

According to the Treatment Advocacy Center (TAC), a national nonprofit dedicated exclusively to eliminating legal and other barriers to treatment of severe mental illness, the National Institute of Mental Health (NIMH) reports that in a given year 1.1 percent of adults in the United States suffer from schizophrenia with only 60 percent receiving health care treatment. In addition, NIMH reports that 2.6 percent of U.S. adults suffer from a bipolar disorder in a given year, with 83 percent of these disorders considered severe, and only 50 percent receiving treatment. According to TAC, individuals with untreated severe mental illness commit at least 10 percent of all homicides, 50 percent of mass killings, and are far more likely to commit suicide. The TAC offers three mental health policy reforms to reduce violence.

Court-Ordered Outpatient Treatment

First, all states should adopt court-ordered outpatient treatment (a/k/a “assisted outpatient treatment” or “AOT”) for individuals with severe mental illness and a history of violence, arrest or re-hospitalization. The Center recommends that HHS establish a national AOT demonstration project providing grant funding for up to 100 AOT programs nationwide. AOT is described by TAC as “court-ordered treatment (including medication) for individuals who have a history of medication noncompliance, as a condition of their remaining in the community.” According to the Center, “[s]tudies and data from [the 44] states using AOT prove that it is effective in reducing the incidence and duration of hospitalization, homelessness, arrests and incarcerations, victimization, and violent episodes. AOT also increases treatment compliance and promotes long-term voluntary compliance, while reducing caregiver stress. The six states that do not have AOT are Connecticut [emphasis added], Maryland, Massachusetts, New Mexico, Nevada, and Tennessee.”

Civil Commitment Reforms

Second, TAC seeks reformation of civil commitment laws to allow intervention in cases of acute psychiatric crisis before violence or suicide occurs. The Center recommends public funding for judicial and law enforcement training to ensure proper implementation of these reforms. In seeking the relaxation of the civil commitment laws, the Center stresses that the public safety is impaired and preventive treatment limited by the continuing misconception in the law that civil commitment requires proof of imminent violence or suicide.

Sufficient Inpatient Psychiatric Beds

Lastly, TAC believes that the government must ensure that sufficient inpatient psychiatric beds are available for those who are unable to safely live in the community. To achieve this goal, the Center recommends the repeal of the Institution for Mental Disease (IMD) Exclusion. The law prohibits Medicaid payment for the care of inpatients between the ages of 22 and 65 in inpatient patient facilities with more than 16 beds where more than half of patients are under treatment for severe mental illness. According to the Center, the IMD exclusion incentivizes states to eliminate public psychiatric beds as a cost-saving measure. Its repeal would help end the discrimination between coverage of medical and mental illnesses.

TAC has urged Vice President Biden’s task force on gun violence to consider these three changes in mental health policy in order to make mental illness treatment available to more individuals at risk for committing violent acts. The President’s plan includes increasing access to mental health services.